01/14/2022

Patient Returning for Warts After Ingrown Toenail Removal

We had a patient with Aetna who had an ingrown toenail removed. She came back 3 months later and had warts on her foot. We billed for 17110 and 99213 with 25 modifier and dx codes B07.0 M79.762 and R26.2 . They denied the office visit stating procedure code incidental to primary procedure. If it was the first time we saw the patient for a wart shouldn’t we be allowed to bill for diagnosing that? We did an appeal and they denied that again, Thanks for your help.

With Aetna, plans will pay for both a minor procedure and an E&M code on the same DOS if the diagnoses codes linked to each procedure substantiate separate payment. With established patients, Aetna will commonly deny the office visit if the diagnosis is not distinct from the minor procedure, or if the coding is very general for the E&M code.

Since the two procedures had the same diagnoses codes linked, the charges were denied by Aetna correctly and no payment will be made for the office visit.

If the coding used on the E&M code is very general and could be interpreted as secondary symptoms to the patient’s chief complaint (warts in this case with pain and edema secondary), that will also be denied as bundled to the wart removal.

If the coding cannot be changed, appealing with office notes would be the method to consider the office visit payment for additional payment. If the appeal was reviewed and the denial was upheld, then the coding between the office visit and wart removal was not distinct enough to justify additional payment. For future encounters, if an E&M code was billed, the diagnosis should be distinct so whether the claim is paid with the initial submission or with office notes from the diagnosis from the minor procedure.